In order to process your background check, there is a $50 fee for you to pay. Please call our office at 706-896-9966 and give us your credit number so we may charge your account the $50 and process your background check. You will be refunded your $50 at the end of one year of service.

After your payment has been processed, PLEASE COMPLETE SECTION 1

and fax to 706-896-4737 or scan & email to

Consent and Authorization Form

Post Office Box 757, Blairsville GA 30514

Tel:706-781-3554Fax:706-781-3907/3808

Email:

Enota 706-896-4765

EMPLOYEE APPLICANT BACKGROUND CHECK AUTHORIZATION/ORDER FORM

The undersigned (i) confirms that it has authorized the above named Client to obtain a background check for employment purposes including, without limitation, a consumer report and criminal background check on the undersigned, and (ii) authorizes Information on Demand, Inc. , or any of its agents, to provide, orally or in writing, the results of a background check, including a consumer report and criminal background check, to the above-named Client or its representatives. I further certify that I have been advised of my rights under the The Fair Credit Reporting Act (FCRA),15 U.S.C. 1681-1681y. either verbally or by inclusion in my employment application package. This authorization is a continuing authorization for the Client to obtain background checks on the undersigned during the term of the undersigned’s employment with Client.

THE UNDERSIGNED RELEASES AND HOLDS HARMLESS INFORMATION ON DEMAND, INC. AND ITS AGENTS AND REPRESENTATIVES, AND ALL ENTITIES AND INDIVIDUALS INVOLVED IN REPORTING INFORMATION ABOUT THE UNDERSIGNED, FROM ANY AND ALL CLAIMS BY, OR LIABILITY TO, THE UNDERSIGNED THAT MAY RESULT FROM, ARISE OUT OF, OR IN CONNECTION WITH THE CHECK AND CONSENTS TO THE ABOVE NAMED EMPLOYER TO PERFORM PERIODIC BACKGROUND CHECKS FOR THE DURATION OF MY EMPLOYMENT WITH THIS COMPANY.

SECTION 1: EMPLOYEE APPLICANT INFORMATION – COMPLETED BY APPLICANT

PRINT HERE:

First NameMiddle NameLast Name

SexRaceDate of BirthSocial Security Number

Complete Street Address, City, State, and Zip Code

Employee Applicant SignatureDate

Client Certifies the following:

  1. The Background Report is being ordered from IOD for use by Client employment purposes.
  2. Information from the Background Reports will not be used in violation of and Federal or state equal opportunity employment law or regulation.
  3. Client has provided to the subject of the Background Report a clear and conspicuous written disclosure, in a document that consists solely of the disclosure, that a consumer report may be obtained on the subject for employment purposes, and the subject has provided written authorization (which may be on the same document) of Client’s procurement of the report.
  4. Before taking adverse action again the subject of the Background Report, based in whole or in part on the Background Report, Client will provide that subject a copy of the report and a copy of the FTC’s Summary of Consumer Rights.

SECTION 2: BACKGROUND CHECK REPORT ORDER – COMPLETED BY ENOTA

 Criminal Trace (Enter One State in Parentheses Below)County Level Search:______

(_____)______(_____)______(_____)______(_____)______

 Social Security Trace M.V.R. State & No.______

 US National Search Education /Employment Trace (Use Attached Sheet)

 I9 Verification (Please attached I9 and copies of documents)

Signature of Client Representative: ______Date: ______

 Work in Elder Care Work in Child Care Work with Mentally Disabled